In the non-ulcerative variety the tu bercles remain practically stationary, then flatten out, and leave in their stead a wrinkled surface, which, as stated, be comes exfoliated, and ultimately disap pears, leaving in its stead a small cicatrix.
The many forms which lupus may assume have suggested an equal number of subdivisions. When the destructive process advances with great rapidity, de stroying everything in its wake, it is termed lupus vorax; when the suppura tion is slight and the lesion is hard, verrucose, or papillomatous, it is termed lupus verrucosus or papillomatosus; when the affected tissues are greatly thickened and deformed, it is termed lupus hyper trophicus, etc.
All the forms of lupus, with the ex ception of lupus vorax, progress slowly. It may, after a period of slow develop ment, become stationary and even recede until complete recovery is attained. This is rarely observed, however. A peculiar ity of the disease is its tendency to be come complicated with other cutaneous disorders: erysipelas, adenitis, epithe liomatous cancer, etc.
Diagnosis. — Lupus vulgaris may be confounded with tertiary syphilis, epi thelioma, rodent cancer, and scrofulo derma. The syphilitic eruption most likely to be mistaken for lupus is a sub cutaneous gumma, which after a time ulcerates and becomes covered with a scab; this heals and others form just beyond, advancing in a serpigenous manner. A scar is formed which resem bles lupus, except that there is pigmenta tion around the patch, and the cicatrix is thinner, softer, and less fixed than lupus.
Epithelioma is more painful, pro gresses more rapidly, and is liable to limmorrhages; lymphatic glands in the neighborhood and the deeper structures arc invaded. The edges of the ulcer, too, are raised and hard. Rodent cancer arises late in life, the edges of the ulcer contain no nodules; and there are no granulations on the ulcer. It is always single, and does not cicatrize spontane ously. (Bidwell.) Pathology.—Walker divides the com moner varieties of lupus into three forms: 1. The ulcerating form, which is most common on the face; the affected area is covered with granulations, giving rise to a purulent discharge, which dries up into a crust. The granulations of this form differ from the granulations of an ordinary ulcer in that they are covered by epidermis. The epithelial cells are
swelled, degenerative, and allow the pas sage of serum and leucocytes. This is due to the secondary inoculation of or ganisms other than the tubercle bacillus.
2. The form in which no ulceration oc curs, a miliary tuberculosis of the skin, which presents multitudes of little tu bercle-follicles which constitute the ap ple-jelly nodules. If a sufficient number of nodules run together, the epidermis is lost, and the area, becoming inoculated with other organisms, gives rise to the form of the disease just mentioned. 3. The fibrous form, in which the patch is usually single, and varies in size from a sixpence up to six inches in diameter. The skin is thickened and red and often scaly. No tubercle can be made out on account of the diffuse redness which masks them.
Prognosis.—The recent contributions to our knowledge of lupus have somewhat improved the chances of recovery; but the disease remains a difficult one to over come, and sometimes seems to baffle all efforts. Again, it may apparently yield to appropriate treatment and suddenly reappear—all features which should sug gest reserve when the physician is asked to express his views.
Treatment.—An important feature of the treatment of lupus vulgaris is atten tion to the general health. It is a tuber culous affection and, therefore, associated with general vital depravity. Out-of door exercise, wholesome food, tonics, etc., tend greatly to assist the local meas ures by increasing the powers of resist ance of the tissues to bacillary invasion.
The reports of numerous operators have shown that many cases of lupus can be cured by radical excision and with good cosmetic results. This mode of treatment should be undertaken at the earliest possible moment. The incision should be made in healthy tissue, at least 1 to 2 centimetres from the infected area, and the tissues thoroughly curetted off. A. Buschke (Berl. klin. Woch., No. 21, '9S) states that if there is any doubt as to how far the tissues are infected, the tuberculin test should be employed. A plastic operation, to cover the defect, should then be resorted to.